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PHYSICAL MEDICINE AND REHABILITATION

RESIDENTS' WEB SITE

Thank you for your interest in the Department of Physical Medicine and Rehabilitation at Temple University School of Medicine.  We hope this site helps answer your questions about our department.

 

PM&R Case of the Month:

 

56-year-old male presents to the hospital with ascending paralysis (PDF)

 

Critical Fact of the Month:

 

Tardieu Scale and the Modified Tardieu Scale (MTS)

 

These scales are clinical measures of muscle spasticity in patients with neurological conditions. The Tardieu Scale and MTS quantify spasticity by assessing the muscle's response to stretch applied at given velocities. The quality of the muscle reaction at specified velocities and the angle at which the muscle reaction occurs are incorporated into the measurement of spasticity using the MTS.

 

The Ashworth Scale and the Modified Ashworth Scale are most often used clinically in the assessment of adults, however the MTS is more commonly used in the assessment of children and has been suggested to be a more accurate clinical measure of spasticity. The ability of the Ashworth Scales to measure spasticity has been questioned and some publications suggest that they measure abnormal tone or resistance to passive stretch rather than spasticity because they do not take into account the velocity-dependent component of spasticity. The MTS compares the muscle's resistance to passive stretch at both slow and fast speeds in order to account for the velocity-dependent characteristic of spasticity.

 

The examiner evaluates the muscle group's reaction to stretch at a specified velocity with 2 parameters: X (quality of muscle reaction) and Y (angle of muscle reaction).

 

Velocity of stretch:
V1: As slow as possible (minimizing stretch reflex)
V2: Speed of the limb segment falling under gravity
V3: As fast as possible (faster than the rate of the natural drop of the limb segment under gravity)

 

The resulting joint angles are defined as:
R1 (the angle of catch following a fast velocity stretch - during either V2 or V3); and
R2 (passive range of motion following a slow velocity stretch - V1)
As V1 is used to measure the passive range of motion (PROM), only V2 and V3 are used to rate spasticity

 

Test positions:
Upper limb - To be tested in a sitting position
Lower limb - To be tested in supine position

 

Scoring:
0 No resistance throughout the course of the passive movement
1 Slight resistance throughout the course of passive movement, no clear catch at a precise angle
2 Clear catch at a precise angle, interrupting the passive movement, followed by release
3 Fatigable clonus (<10 seconds when maintaining pressure) occurring at a precise angle
4 Indefatigable clonus (>>10 seconds when maintaining pressure) occurring at a precise angle
5 Joint is immovable

 

For an in depth review of the scales and score interpretation, refer to the following site:
http://strokengine.ca/assess/module_mts_indepth-en.html

 

Monthly Sign:

 

Holmes' Tremor:


First identified by Gordon Holmes in 1904, Holmes' tremor or rubral tremor designates a combination of rest, postural, and action tremors due to midbrain lesions in the vicinity of the red nucleus, with combined disruption of dopaminergic nigrostriatal and cerebellorubrothalamic tracts. This type of tremor is irregular and low frequency (below 4.5 Hz). Signs of ataxia and weakness may be present. Common causes include cerebrovascular accident and multiple sclerosis, with a possible delay of 2 weeks to 2 years in occurrence of lesions and tremor onset. Rehabilitation difficulties out of proportion to the motor deficit can be present. Case reports suggest that pharmacologic or neurosurgical intervention may help.


An example of Holmes’ Tremor can be viewed here:


http://www.neurology.org/content/suppl/2010/07/24/75.4.e10.DC1/video.mpg

 

 

Osteopathic Medicine of the Month:

 

Facilitated Positional Release (FPR):


A passive, indirect technique in which tissue and joint tension is first neutralized (diminished), followed by compression (an activating force) and then addition of freedom of motion in side-bending and rotation (indirect position). Successful FPR treatment resets the muscle spindle reflex. Common indications for FPR include hypertonic muscles (superficial or deep) and somatic dysfunctions (type I and II).

Example:
Dysfunction: Cervical muscle tension
Objective: Relax tight muscles
Patient Position: Supine
Physician Position: Seated at the patient’s head


Procedure:

  1. Cup the patient’s neck in the palm of your hand, with the pad of the index or long finger (acting as both monitoring finger and fulcrum) on the contralateral tense tissue to be treated. Your thumb rests on the other side of the neck.
  2. Using your non-monitoring hand on the top of the patient’s head, straighten the cervical lordosis by slightly forward bending the neck.
  3. Using the same hand, apply a compressive facilitating force to the neck, through the patient’s head.
  4. Maintaining the compressive force, introduce extension to the neck to the level of the monitoring finger. (If the tissues being treated are anterior rather than posterior, introduce flexion rather than extension.) This should cause a palpable softening of the tissue being treated.
  5. Add side-bending and rotation, usually toward the side of the tense tissues to the point that the tissues continue to soften.
  6. Hold the tissue in this relaxed position for three seconds, and then return the neck slowly to a neutral position.
  7. Reassess the tissue being treated.

 


 

 

 

Rehab in Review Summary Guidelines

 

Summaries should be between 200 and 250 words. Summaries should begin with a one or two sentence statement indicating why the study was done. This is usually obvious from the introduction to the article itself. This should be followed by a short paragraph indicating what was done, and then a paragraph indicating what was found. The summary should end with a one to two sentence summary of the findings. This allows the reader to either review what was just read, or refresh his/her memory after reading the summary.

 

I realize that the length restriction is difficult. As a suggestion, the methodology is the easiest area to truncate, leaving the reader with the gist of what was done. The details can be obtained from the full article by those who desire them. Please make all of the summaries factual, with no injection of personal opinion.

 

Please include:

  • Submitted by: Your name, title, and residency program
  • Article title
  • Journal name with volume number, issue, and page numbers